SH CP 204

Electrocardiograph (ECG) Policy Version: 1

Summary:

The aim of the ECG policy is to provide pragmatic advice as to what is best practice and inform clinicians of potential cardiac risks to patients treated in mental health services.

Keywords (minimum of 5): (To assist policy search engine)

Medication, Effects, Cardiovascular, Physical, Health, ECG, Electrocardiogram, HDAT

Target Audience:

All Clinical/Social Care Staff

Next Review Date:

January 2018

Approved and Ratified by:

Medicines Management Committee

Date issued:

January 2017

Author:

Juliet Wells, Principal Pharmacist

Sponsor:

Mayura Deshpande, Clinical Service Director, Adult MH

Date of meeting: 16 November 2016

1 Electrocardiograph (ECG) Policy Version: 1 January 2017

Version Control Change Record Date

Author

Version

Page

2014 2014

Juliet Wells Tim Coupland, Dr Raja Badrakalimuthu Dr Daniel Pearce Dr Amanda Taylor, Steve Coopey Ricky Somal Juliet Wells Francis Johnson, Deputy Chief Pharmacist

1 1

All All

Review and transferred to SHFT format “

1 1 1 1

All All

Reviewed, TNA completed Reviewed EqIA completed Medicines update Amendments following MMC

2016 2016 2016 2016

Reason for Change

Reviewers/contributors Name

Medical Advisory Committee Medicines Management Committee Medicines Committee Management Rebecca Henry

Position

Version Reviewed & Date V1 2014 V1 2014 V1 2016 V1 2016

2 Electrocardiograph (ECG) Policy Version: 1 January 2017

CONTENTS

Page 1. 2. 3. 4. 5. 6. 7.

Introduction Background Procedure Training Important Note Monitoring Associated documents

4 4 5 8 8 9 9

A1 A2 A3 A4 A5 A6

Appendices Psychotropic medication effects on QTc interval ECG Fax Back Service form ECG Fax Back Service ECG Easy Guide Training Needs Analysis (TNA) Equality Impact Assessment (EqIA)

10 12 13 15 16 17

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ECG Policy 1.

INTRODUCTION

1.1

The aim of the ECG policy is to provide pragmatic advice as to what is best practice and inform clinicians of potential cardiac risks to patients treated in mental health services.

2.

BACKGROUND

2.1

Increasingly there is recognition of the cardiotoxic effects of psychotropic medication as well as the effect of physical intervention such as restraint. This is a summary of the information available and some of the factors that increase cardiac risks: i) The drug factors ii) Patients factors that increase cardiac risk

2.2

Drug Factors:

2.2.1

QTc effects Many psychotropic drugs are associated with ECG changes and it is possible that certain drugs are causally linked to serious ventricular arrhythmias and sudden cardiac death. Some antipsychotic drugs block cardiac potassium channels and are linked to prolongation of the QT interval which is a risk factor for ventricular arrhythmias which are occasionally fatal. Tricyclics antidepressants are sodium channel antagonists which prolong QRS and QT interval effects. These are usually evident only following overdose (see Appendix 1). Concurrent use of more than one QTc prolonging drug

2.2.2

Metabolic Inhibition The effect of drugs on the QTc interval is usually plasma level dependent (i.e. dose) and drug interactions are therefore important, especially when metabolic inhibition results in increased plasma levels of the drug affecting QTc. Examples of metabolic inhibitors are : - Fluvoxamine, Fluoxetine, Paroxetine and Valproate.

2.2.3

Other Cardiac Effects Clozapine is associated with tachycardia, myocarditis, cardiomyopathy and atrial fibrillation (AF). Olanzapine, Paliperidone & Tricyclic antidepressants are associated with AF. Anticholinergics are associated with tachycardia. Acetylcholinesterase inhibitors used in management of dementia are associated with bradycardia and asystole. Also consider concurrent diuretic therapy and digoxin

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2.3

Patient Factors:

2.3.1

Physiological risk factors for QTc prolongation and arrhythmia These include pre-existing cardiac disease, long QT syndrome, bradycardia, ischemic heart disease, myocarditis, myocardial infarction, left ventricular hypertrophy, recent cardioversion with QT prolonging drug, metabolic causes, hypokalaemia, hypomagnesaemia, hypocalcaemia, extreme physical exertion, stress or shock, genetic predisposition, anorexia nervosa, malnourishment, extremes of age i.e. children or elderly and female gender, renal or hepatic impairment.

2.3.2

Patient cardio vascular risk factors: With respect to cardio vascular disease, other risk factors are: smoking, elevated lipids, family history of heart disease/QTc prolongation, obesity and life style issues. Obesity and impaired glucose tolerance represent a much greater risk to patient morbidity and mortality than the uncertain outcome of QTc changes.

2.3.3

Behaviours responsible for increased risks: Restraint and rapid tranquillisation of patients, and particularly the use of high dose antipsychotics, are associated with increased cardiac risk factors. A history of illicit drug use, may compound the risks due to possible increased heart rate, exhaustion, hypotension and excitement. Patients on drugs such as methadone and cocaine which are associated with cardiogenic effects are recommended to have ECG at baseline.

3.

PROCEDURES

3.1

Which patients require an ECG?

3.1.1

Before starting any psychotropic medications an electrocardiogram (ECG) should be offered if:  specified in the summary of product characteristics (SPC)  physical examination shows specific cardiovascular risk (such as diagnosis of high blood pressure)  there is personal history of cardiovascular disease, or  the service user is being admitted as an inpatient  or indicated in physical health monitoring guideline

3.1.2

For patients on high dose antipsychotics or antipsychotics such as Clozapine and Pimozide with high risk of cardiotoxicity regular ECG monitoring will be required. Regular monitoring may be required for patients on specific antidepressants such as Citalopram and high dose venlafaxine. Please refer to physical health monitoring guide for frequency of ECG monitoring.

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Indications for ECG Monitoring Psychotropic medication

ECG Monitoring

Acetylcholinesterase inhibitors (APT,2007, 13, 178-184)

Baseline : If pulse > 60 bpm but with history of falls, syncopal attacks, on cardiovascular medications for rate/ rhythm control or with significant cardiovascular illness or if pulse 150mg/day and in patients with risk factors for QT prolongation, or symptoms that may be attributable to arrhythmia

If an ECG cannot be carried out because of a patient’s mental state or behaviour (e.g. on admission to an inpatient unit) then this fact and the reasons, must be recorded in the primary case record. An ECG should be done as soon as it is 6

Electrocardiograph (ECG) Policy Version: 1 January 2017

practical. An ECG should be carried out once the medication dose has been stabilised. 3.1.4

All patients over 45 years old or all patients with a history of cardiac problems or cardiac risk factors should have an ECG prior to ECT. Please refer to the ECT policy (CP69.1) on the Trust Website.

3.1.5 All patients prescribed two or more medications which impact on QTc interval or associated with arrhythmias should have ECG as recommended by the Physical Health Monitoring Policy of Southern Health NHS Foundation Trust. 3.1.6

Routine baseline ECG may not be required when medications such as Citalopram or Risperidone is used in small doses and for a short duration in managing behavioural and psychological symptoms of dementia.

3.2

Equipment

3.2.1

Each inpatient unit should have an ECG machine which should be kept in good working order

3.2.2

The preferred ECG machine for use within Southern Health NHS Foundation Trust is GE MAC 1200ST with interpretation module. When an ECG machine requires replacement this should be the preferred model of choice.

3.2.3

It is the responsibility of the Modern Matron in each in-patient unit to ensure the functioning and maintenance of the ECG machine.

3.3

Inpatient Services

3.3.1

Each inpatient unit must have an understanding about who does the ECG, how it is interpreted and when to refer to for specialist opinions. These arrangements will be agreed at a local level.

3.3.2

All inpatient services have to access a Fax Back service for cardiology opinions from Portsmouth Hospital Trust. The request sheet should be completed for all requests (appendix 2 & 3). However, some inpatient units may have arrangements with their local cardiology teams and with whom they can agree appropriate referral criteria.

3.3.3

Modern Matrons (or equivalent) are responsible for ensuring all clinical staff know the local procedures for arranging ECGs.

3.4

Outpatient Requirements

3.4.1

In general the GP will be responsible for prescribing medication and therefore also the appropriate monitoring. However, whenever a psychiatrist recommends any medication, they should inform the GP of the monitoring requirements.

3.4.2

If the psychiatrist retains responsibility for prescribing, they are also responsible for ensuring that the drug monitoring requirements, including ECG, are met e.g. in the case of Clozapine, HDAT or depot medication.

3.4.3

Local arrangements will need to be made concerning how the ECG is obtained i.e. through the GP or local general hospital. ECG results must be recorded in the appropriate place in the care record and the GP informed.

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3.4.4

ECGs should be included as part of the Care Planning process with reference to the physical health shared care guidelines.

3.5

Practice

3.5.1

See Appendix 4 for flow chart.

3.5.2

Once the ECG has been carried out the following guidelines for referral should be followed:

3.5.3



QTc